Abstract

Swaziland has the highest HIV prevalence rate in the world, despite the billions of dollars' worth of prevention efforts mobilised to curtail the epidemic. In this article I will argue that Swaziland's HIV prevention campaign fundamentally misperceives the causes of the epidemic by focusing on individual behaviour change to the exclusion of the wider socio-economic context of disease transmission. This model derives from a western biomedical paradigm that fetishizes the individual as the locus of responsibility and obscures the structural violence that constrains people's agency. Over the past few decades, Swaziland has been subject to a regimen of neoliberal economic policies that have created an environment of unprecedented HIV risk. Structural adjustment programmes and export-oriented investment strategies have led to declining rates of economic growth, formal employment and agricultural productivity, exacerbating pressures for labour migration and transactional sex among poor households. At the same time, free trade agreements have hobbled the public health system and prevented the rollout of antiretroviral therapy. This article concludes that high HIV prevalence in Swaziland is less a biomedical condition than a symptom of neoliberal market policy and that the burden of behaviour change should lie not with HIV patients but with the architects and beneficiaries of the prevailing economic order.